Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care

Background Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups. Methods This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis. Results Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions. Conclusions This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-024-04919-0.


Background
Up to 60% of persons living with dementia (PLWD) in LTC experience agitation and/or aggression symptoms, with the prevalence varying based on dementia pathology and severity [1].Although agitation and aggression are separate constructs, they are often presented together among PLWD in LTC [2].Agitation consist of three main domains outlined by the International Psychogeriatric Association criteria for Agitation in Cognitive Disorders: 1) excessive motor activity, 2) verbal aggression, and 3) physical aggression [3].Aggression refers to verbal and physical behaviours (e.g.hitting, throwing, etc.) that are highly likely to cause harm among the resident and others [4][5][6].Agitation and/or aggression can adversely impact residents' quality of life by increasing the likelihood of falls, fractures, and developing additional neuropsychiatric symptoms, as well as increasing the cost of care and the rate of institutionalization [1,7].Corresponding caregivers often experience increased burnout, lower job satisfaction, stress, and worse psychological health [8].Given the burden that agitation and/or aggression have among PLWD in LTC and their caregivers, more emphasis is needed on treatment strategies.
Agitation and/or aggression can be treated via either pharmacological (drug) or non-pharmacological (nondrug) interventions.The former consists of psychotropic medications, such as antipsychotics (e.g.risperidone or olanzapine) or antidepressants (e.g.citalopram).However, psychotropic medications can lead to adverse side effects including stroke and decreased cognitive function [9,10].For example, antipsychotics confer a higher risk of adverse events, such as falls, fractures and deaths [11].Moreover, the efficacy of psychotropic medications to alleviate agitation symptoms is contested [9].In comparison, non-pharmacological approaches include sensory practices (e.g., aromatherapy), psychosocial practices (e.g., validation therapy), and structured care protocols (e.g., bathing) [12].Non-pharmacological approaches are considered first-line treatment strategies to address agitation among PLWD because they confer less side effects and are efficacious [13].For example, Watt et al. (2019) ranked outdoor activities as highest in efficacy to address combined aggression and agitation, along with physical aggression independently [11].Despite this knowledge, non-pharmacological treatment approaches are underused in clinical practice [9].
Many challenges exist to managing agitation and/or aggression in LTC, but prior qualitative studies focus on understanding only nursing and physician perspectives, and lack qualitative perspective on the care needs of PLWD experiencing agitation and/or aggression [9,14].As such, there is a lack of understanding on the perceived barriers and facilitators to care for other key stakeholders involved in the care and/or planning of care for PLWD in LTC (e.g., patients, families, allied healthcare workers, etc.).The purpose of this study is to assess what barriers and facilitators to care exist for agitation and/or aggression among PLWD in LTC centres, as perceived by all key stakeholder groups.

Ethics
Ethics approval was acquired through the Conjoint Health Research Ethics Board (REB-22-1100), and permission was granted from all organizations.

Participant recruitment
Rolling, snowball and purposive sampling of participants were used, with the latter ensuring representation of diverse sex, gender, race/ethnicity, and urban/rural perspectives.We recruited persons working across healthcare disciplines (e.g., physicians, nurses, allied healthcare workers, etc.).70% of the total resident population, and an estimated 89% of care staff, are female in LTC [15,16].Therefore, to ensure fair representation, male participants were purposively recruited across all disciplines [15].Participants were recruited from urban, suburban and rural sites to increase understanding of the organizational differences and similarities between geographical regions.
Recruitment posters and email advertisements were sent out across four local LTC facilities.The study team further recruited participants via our own networks.To ensure representation at a national level, advertisements were posted to social media platforms (e.g., Twitter).Lastly, persons who consented to participate in a previous Delphi panel study developing a novel care pathway for agitation and/or aggression among PLWD in LTC could also consent to being contacted about participating in a semi-structured interview [17].In the Delphi study, panelists were recruited to complete several rounds of a Delphi survey to create a clinical care pathway suitable for the identification, diagnosis, and management of agitation and/or aggression symptoms among PLWD in LTC [17].Panelists were recruited via the same 4 LTC centres via purposive and snowball sampling using poster and email advertisements [17].They were also recruited via research team contacts and networks [17].
Semi-structured interviews (45 to 60 min) were conducted one-on-one with participants until thematic saturation was reached.No compensations were offered to participants of the study.

Data collection, storage and management
Interviews occurred online using a password-protected meeting using the platform "Zoom" in a confidential environment.Participants' personal information was not shared outside of the research team.All interviews were conducted, transcribed, and verified by one researcher.The interviewer is a cis female graduate student.The interviews were audio recorded using an audio recorder, de-identified using pseudonyms, and transcribed verbatim using the A.I software "Otter.ai".If audio recordings had identifying information, they were transcribed by hand.Each transcript was verified against the corresponding audio recordings for accuracy.All original recording files will be kept on the password-protected university server for a minimum of 5 years following transcription, in accordance with [redacted] data retention policies.

Interview guide development
Interview guides were developed by the research team based on existing evidence, expert experience and framed with the Theoretical Domains Framework (TDF), as it identifies influences on healthcare providers' and patients' behaviours relative to evidence-based recommendations [18].The TDF was chosen over other frameworks because it comprehensively captures a range of mechanisms that influence behaviours, creating a foundation for prospective behaviour change interventions [19].The TDF can be mapped to the Capacity, Opportunity, Motivation Model of Behaviour (COM-B) within the Behaviour Change Wheel (BCW) [20].The COM-B can then be used as a stepping stone to link these sources of behaviour to behaviour change interventions and clinical implementation [21].
Two separate interview guides were created for: 1) healthcare practitioners (e.g., physicians, nurses, allied healthcare workers) and; 2) caregivers and family members.Questions covered all 14 domains of the TDF (e.g., knowledge, skills, etc.).The interview guides can be found in Additional File 2. The aforementioned definitions of agitation and aggression were followed when creating the interview guide.Barriers/facilitators that may exist at diagnosis/detection, care management and coordination, and treatment (mild/moderate and severe/ acute) of agitation and/or aggression were explored among PLWD in LTC.The guide was adapted for suitability and/or appropriateness to ensure both caregivers and healthcare practitioners could answer.

Descriptive statistics
Demographic data was summarized from all interview participants.Characteristics included sex, gender, age, place of birth, languages spoken, racial identity, occupation or role in LTC, and length of career or number of years in their role.These data were reported in a table, providing rich, descriptive context of the interview participants overall (Table 1).

Framework analysis
The transcribed interviews were coded using Framework Analysis, based on the TDF.Framework analysis determined how interview discussions fit within the TDF.It follows 7 steps described by Gale et al [22].
An inductive, ground-up coding process was conducted by two independent researchers by analyzing each line of transcript one-by-one.Codes emerged as the data were analyzed.Codes were then deductively analyzed by one researcher, by grouping them into themes and assigning TDF domains to them.Each code could be associated with one or more TDF domain.The themes were further grouped into categories of care for agitation and/or aggression: 1) Detection/diagnosis, 2) Care coordination and management, and; 3) Treatment (mild/ moderate and acute/severe).Further interpretation was made on what domains of the TDF were contributing the most as barriers/facilitators to care.
Data saturation was considered reached when no new themes regarding barriers and facilitators to agitation care emerged from the discussions [18].As new themes continued to arise with coding, more participants from the respective stakeholders were recruited via purposive and snowball sampling until data saturation was achieved, and possible themes were exhausted.

Reporting criteria
Results were reported as per the 32-item COREQ checklist for explicit reporting of qualitative studies involving semi-structured interviews [23].A reflexivity statement is shown in Additional File 1.

Organization of Findings
Results are presented as barriers and/or facilitators across several larger categories (Fig. 1): (1) detection and diagnosis, (2) Care coordination and management, (3) Mild-to-moderate Treatment, and (4) Acute/ Severe treatment.Themed codes and associated interviewee quotes are indicated by italics as shown below.Tables 2, 3 and 4 demonstrate all codes and categorized themes which depict all barriers and facilitators to care identified during the interviews, with detailed quotes in Additional File 3. Participant roles were anonymized to protect participant confidentiality, but Participant ID is shown to represent diverse participant perspectives.

Barriers and facilitators to care at detection and diagnosis of agitation and/or aggression
Several main facilitators were described at detection and diagnosis.Agitation diagnostic tools were reported as advantageous because they can be easily administered by different healthcare professionals and produce easyto-understand results.As well, using agitation diagnostic tests were considered useful because they allow healthcare practitioners to compare agitation between residents and keep assessments objective.Interview participants also advocated for increased training among healthcare providers to use agitation screening tools.Lastly, allied healthcare workers praised using the Resident Assessment Instrument (RAI) along with counting the number of aggressive or agitated incidents as facilitators to diagnose agitation.Several barriers to care at detection and diagnosis were identified.Firstly, certain diagnostic tests may prove difficult to administer because they are not adapted for persons with cognitive impairment.Interviewees reported difficulties in understanding how agitation diagnostic tests work.And, differing levels of healthcare provider familiarity with agitation diagnostic tools may affect how comfortable and competent they are with administering them.There were logistical challenges to using agitation tools because tools were commonly time consuming, and required adequate healthcare provider availability.

As well, diagnosis of cognitive issues took a long time, which delays diagnosis of agitation and/or aggression: "[T]he whole process of diagnosis took about three years, and the cognitive neurologist was seeing us every six months, and she would test him every time with different mental tests…" (Participant 1)
Furthermore, diagnosis of agitation and/or aggression took a long time, which can delay the onset of treatment.Another caregiver described a lack of available diagnostic tests for agitation for PLWD in LTC.Diagnostic care practices also commonly overlook hypoactive behaviours in dementia that are comorbid to agitation and/or aggression:        Although cognitive impairment and hypoactive behaviours are not specific to agitation and/or aggression, a delay in diagnosis of cognitive impairment was interpreted by participants to consequently delay the detection of associated agitated and/or aggressive behaviours.

Barriers and facilitators to coordination and management of care of agitation and/or aggression
A key facilitator to the coordination and management of care was using family members to help provide care, to help calm residents and direct the course of care.Secondly, interviewees supported using personalized and interdisciplinary approaches to care to improve confidence in care plans.Components of personalized care included having a supportive and personalized environment for the resident to physically live, and having a checklist of precipitants to consider (e.g., basic needs, food, etc.) for each resident.As well, specialized or interdisciplinary care teams were needed to develop care plans and management strategies: "[W]e do have our interdisciplinary team that regularly debates and we discuss each resident several times a year, and then more so if needs arise.And so it's anywhere from HCA to physio, TRT, social work, dietary, the entire interdisciplinary team." ( Participant 10) In terms of barriers, several participants reported a lack of action among care workers to address agitation and/or aggression concerns among residents, and a lack of staff-to-staff and staff-to-family caregiver communication as a barrier to consistent and quality care for agitation.There were cultural and language barriers to care for residents identifying as persons of colour, and constantly changing directives in LTC facilities or a lack of existing directives to address agitation and/or aggression.Environmental barriers included the presence of constant loud noises and unideal room configurations for PLWD in LTC.Finally, a lack of available resources to provide care was raised as a crucial barrier to care, with a particular focus on the cost of care, staffing issues and limited time for healthcare providers to provide care.Various barriers to using medication to treat mild-tomoderate agitation and/or aggression included barriers due to biological mechanisms, presentation of severe agitation, and drug shortages and availability.There were also challenges in identifying side effects from the drugs, in monitoring the medications, and in physically administering medication to residents: "Challenges in administration.Challenges if there is not enough monitoring to see the effects of these drugs.Challenges in explaining to the caregivers what to look for in terms of side effects or other effects from the drugs." (Participant 6)

In terms of barriers to using non-pharmacological interventions for agitation and/or aggression, interviewees reported a lack of training specifically for non-pharmacological treatment approaches among healthcare providers, and a lack of non-pharmacological interventions available in LTC. A logistical challenge included difficulty coordinating timing for interventions among groups of residents.
Treatment strategies often relied on medication because it is convenient, with an easy access to prescriptions for agitation medications, thus non-pharmacological interventions were underused.The need to use trial and error to select a non-pharmacological intervention was also inconvenient.Several codes arose regarding barriers and/or facilitators to care at a systemic and policy level in LTC.An unclear awareness or availability of geriatric medicine or geriatric psychiatry services in LTC served as a barrier at the detection and diagnosis of agitation and/or aggression.Conversly, having physicians more actively involved in care in LTC centres resulted in less referrals and was a facilitator to care at detection and diagnosis.Lastly, as previously mentioned, interviewees reported that having a least restraint policy in LTC was a facilitator to providing non-pharmacological interventions.

Discussion
This study identifies key barriers and facilitators to care behaviours for agitation and/or aggression among PLWD in LTC, across 4 major categories: (1) Detection and Diagnosis, (2) Care Coordination and Management, (3) Treatment for mild-to-moderate agitation and, (4) Treatment for acute/severe agitation.Key barriers across the spectrum of care included a limited number of agitation and/or aggression diagnostic measures, a lack of training for managing agitation and/ or aggression in LTC, an overuse of physical and chemical restraints among acutely/severely agitated and/or aggressive residents, and an underuse of non-pharmacological interventions.Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions.Ultimately, these results advance the care for PLWD in LTC by highlighting key issues needing to be addressed.The findings will support future implementation research endeavours to combat these barriers through targeted interventions to improve the quality of care across Canada.

Specific tools used to detect and diagnose agitation and/ or aggression among PLWD in LTC
The most frequently reported methods of diagnosing and monitoring agitation and/or aggression symptoms in LTC centres was through two main charting means: the Behaviour and Symptom Mapping Tools and the RAI (RAI-Minimum Data Set (MDS) 2.0).Interestingly, no interviewee mentioned the use of an agitation and/or aggression psychometric tool, bringing the availability of agitation and/or aggression diagnostic tools in LTC into question.This barrier relates to issues with availability of resources in LTC.Most of the psychometric tools examined in a recent systematic review were not compared to a reference standard, and there were no studies that examined the BSMT or RAI-MDS 2.0 questions [25].Therefore, there are no reported sensitivity, specificity, or minimally clinical important difference measures seen for these tools.In turn, it is unclear how these tools perform clinically.There are many reasons for this -agitation and aggression are very prominent observable symptoms, and their reporting needs to be tied to antecedent events through informant accounts to be useful to healthcare providers [26].As well, behavioural and psychological symptoms of dementia (BPSD) often overlap, with agitation and aggression often expressed together, resulting in conflation between symptoms [2].Beyond tools, there are also other comprehensive approaches to assessing agitation and/or aggression described in the literature, such as the "Describe, Investigate, Create, and Evaluate" (DICE) method [27].These approaches were also not mentioned in the interviews.To ensure residents are receiving the best means of agitation and/ or aggression detection and diagnosis, more research is needed to validate current tools among PLWD in LTC, and determine whether psychometric tools should be implemented in regular practice.

Using an interdisciplinary care team to diagnose agitation and/or aggression among PLWD in LTC
The diagnosis for agitation and/or aggression is typically finalized by physicians in LTC, using aggregated information collected from members of the interdisciplinary care team.The collaborative approach to care, where all interdisciplinary healthcare providers and/or friends and family caregivers have input into resident care plans, is crucial to the diagnosis and management of agitation and/or aggression.This facilitator demonstrates strengths pertaining to reinforcement of practices, healthcare providers' perceived identity, and creating goals of care.A collaborative, interdisciplinary approach effectively offsets physician time and increases confidence among physicians to make diagnoses [28,29].As well, residents receive a comprehensive assessment outside of a physician's diagnosis, using the maximized complementary strengths of the entire care team [28,29].Interdisciplinary care teams uphold person-centred care values, by addressing the unique needs of each resident whilst giving shared decision making to healthcare providers, residents and family and/or friend caregivers [28,29].Given the benefits, any chosen method to detect or diagnose symptoms of agitation and/or aggression should account for interdisciplinary teams and family and/or friend caregivers.
In a recent systematic review, the majority of agitation and/or aggression tools lacked a comprehensive, interdisciplinary assessment of residents [25].The Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and the Neuropsychiatric Inventory (NPI) were the only tools that seemed to account for multiple stakeholder perspectives (i.e., assessing caregiver distress along with resident symptoms).A potential reason for this is that agitation and/or aggression symptoms are predominantly detected via the observation of residents, or through informant reports of the frequency of symptoms, resulting in only observation-based and informant-rated tools available [26].However, these assessment methods are limiting, where only observable points of contact with the resident can be evaluated [26].More research is thus needed to determine whether incorporating an interdisciplinary evaluation approach into current assessment methods is more clinically beneficial to residents.

Lack of training for managing agitation and/or aggression
Family/friend caregivers and allied healthcare workers felt that training in LTC is inconsistent, lacks staff-to-staff and staff-to-family caregiver communication, and does not properly address resident needs.These issues relate to several challenges, including issues with knowledge and skills among healthcare providers, limited resources, and challenges in staff 's perceived identity.Ultimately, training standards within LTC settings vary province-toprovince across Canada [30].Training for crucial healthcare practitioners in LTC (e.g., physicians, nurses) is not standardized, and often does not embrace a geriatricfocused lens [30].In the analyses, interviewees raised concerns that these variable care protocols for agitation and/or aggression do not meet residents' needs.The variability seen in training adversely impacts management of agitation and/or aggression among PLWD in LTC.There is a need for standardized practices for addressing agitation and/or aggression symptoms among PLWD in LTC among healthcare practitioners in LTC, to improve the efficiency and quality of care.

Underusage of non-pharmacological interventions:
Non-pharmacological interventions are considered more efficacious than pharmacological for agitation and/or aggression due to less adverse side effects, greater cost efficiency, and because they address underlying resident needs [11,31].Despite this knowledge, healthcare providers lacked education and training on how to administer different non-pharmacological interventions, thus serving as a crucial barrier to agitation care.This barrier reflects issues in resources along with knowledge and skills among healthcare providers.One reason for why knowledge and training are lacking is that processes of selecting and administering non-pharmacological interventions are largely unsystematic and reportedly based on trial-and-error [32].Consequently, due to time constraints, healthcare practitioners interviewed in this study often resided to using pharmacological interventions rather than non-pharmacological, out of convenience.This issue was corroborated by Janzen et al. 's (2013) findings, where unpredictable environmental factors and healthcare provider and/or resident personal traits (i.e.personality) resulted in arbitrary selection of non-pharmacological approaches [9].
Through the discussions, a key theme that emerged was a need for better upstream, person-centred approaches for the prevention of agitation and/or aggression.For example, one participant noted that physicians are active in LTC and respond quickly to behaviours, but a separate participant pointed out that such responses typically resort to using chemical restraints (Additional File 3).This issue highlights how agitation and/or aggression are currently being addressed in a downstream manner, after behaviours have manifested.Ultimately, personcentred approaches to prevent agitation and/or aggression use individual unique characteristics, strengths, and weaknesses to recognize and meet individual unmet needs, thus preventing agitation and/or aggression prior to their onset [33].A previous meta-analysis demonstrated that using person-centred care interventions significantly reduces agitation amongst other neuropsychiatric symptoms [33].For example, the "Treatment Routes for Exploring Agitation" (TREA) program, along with other therapeutic recreation programs, provide tailored activities to residents, and have demonstrated a reduction of agitation between 10-14 days following completion of these interventions [33].Therefore, a greater emphasis on person-centred, upstream interventions is needed in LTC to prevent the onset of agitation and/or aggression among residents.
Another issue brought up by family and/or friend caregivers, was the limited number of available nonpharmacological interventions in LTC.Non-pharmacological interventions follow a person-centred approach to address unique behavioural needs of each resident [34].However, to tailor approaches to each resident, nonpharmacological interventions require extensive time and staffing resources to implement -both of which are lacking in LTC [9].Both factors are common barriers to implementing non-pharmacological interventions across a range of behavioural symptoms in LTC [24].For example, Hussin et [36].The onset of COVID-19 has further exacerbated issues in staffing and time to provide care [36].Due to these constraints, a restricted number of non-pharmacological interventions are offered in LTC, thus negatively impacting the quality of care for residents experiencing a variety of health conditions.Given the widespread negative impacts, upstream implementation research is needed to counteract these time and resource constraints, allowing space for more non-pharmacological intervention strategies in LTC.

Overuse of physical and chemical restraints for acute/ severe agitation and/or aggression
A key barrier at acute/severe treatment for agitation and/ or aggression was the reliance on physical and chemical (i.e., fast-acting medications) restraints to contain an acutely agitated and/or aggressive resident.This issue relates to challenges in regulating resident behaviours and reinforcement of practices.Acutely agitated and/ or aggressive residents were considered at risk of harming themselves or others, thus as needed antipsychotic medications (e.g., Haldol) and mechanical restraints (e.g., chair with a seatbelt) were used.These measures carry significant risks to residents including a loss of dignity, social isolation, shame, and physical harm [37,38].
Many LTC institutions across Canada have implemented a "Restraint as a Last Resort" policy, where the least restrictive pharmacological, environmental, mechanical, and physical restraints are administered as a last resort practice [39].Across provinces, similar policies have been implemented by LTC organizers, including Alberta Health Services, Health Prince Edward Island, and the College of Nurses of Ontario [39][40][41].Despite least restraints being a shared goal across Canadian LTC centres, the discussions seemed to highlight an increased use of them among residents.Future studies should evaluate whether current uses of restraints across Canadian LTC centres are appropriate.
Several interviewees highlighted redirection, resident isolation and Gentle Persuasive Approach training.Other non-pharmacological approaches seen in the literature for acute/severe agitation and/or aggression include, but are not limited to, non-coercive verbal deescalation or self-soothing techniques [42,43].However, there are barriers to the use of these interventions.
This study featured a myriad of perspectives from persons of differing roles in LTC (Table 1).Due to these diverse roles, different interviewees focused on different points of discussion.For example, physicians presented a clinical lens during discussions on the detection and diagnosis of agitation and/or aggression, along with corresponding pharmacological interventions.In terms of the latter, physicians spoke to barriers in using pharmacological interventions from the pathophysiological aspect, including drug-drug interactions, and biological mechanisms (Additional File 3).In comparison, nurses and allied healthcare workers focused on challenges in the administration of medications, while family caregivers and spouses focused on education barriers surrounding medication use.Furthermore, allied healthcare workers and nurses provided shared experiences regarding the coordination of care for agitation and/or aggression.In particular, allied healthcare workers (E.g.; occupational therapists, recreational therapists) had notable experience conducting non-pharmacological interventions with residents in LTC, and could speak to the barriers and facilitators they had encountered.Lastly, caregivers and spouses presented ideas throughout their interviews from the residents' perspectives, with themes surrounding their perceived quality of life in LTC.
Few qualitative studies are currently available on the barriers and facilitators to neuropsychiatric care among Canadian LTC centres.Current qualitative literature identifies barriers and facilitators to small-scale implementations in Canadian LTC centres, such as the PIECES education framework [44], but broad-scale qualitative behavioural research has not been conducted.One systematic review exists on the barriers and facilitators to complex interventions for PLWD in LTC, but this study does not focus on widescale barriers to neuropsychiatric care in LTC, and only features 2 studies with a Canadian setting [45].Taken together, this gap in research can have negative clinical implications, as key barriers to care in Canadian LTC centres are missed.This study thus serves as a crucial step in improving understanding of agitation and/or aggression care in LTC, accounting for a broad range of lived experiences and perspectives.
At a broader context, several findings consistent with studies conducted at a global scale were acquired.For example, interviewees detailed cost barriers, disproportionate staff-to-resident ratios, and limited time to provide care as barriers to coordinating and managing care in Albertan LTC facilities.These findings were also reported by Janzen et al. (2013) and McArthur et al. (2021), where limited time to deliver care and inadequate staffing were also and pervasive issues [9,30].Similarly, environmental barriers to agitation care were found, including loud noises and unideal room configurations.This finding is corroborated by Cohen-Mansfield et al. 's (2012) study, where environmental conditions also served as barriers to administering non-pharmacological interventions for a range of behavioral symptoms [24].Taken together, each of these barriers have served as perpetual challenges over the last decade in diverse LTC settings across North America.These findings thus demonstrate the need for a substantial global knowledge-toaction plan to address these pervasive challenges.

Limitations and Generalizability
There were several limitations in this study.Despite aiming to interview participants from a broad array of backgrounds and disciplines, the majority (83.3%) of participants identified as White.The lack of diversity in our sample may not reflect the perspectives of persons of colour working or engaging in LTC.Likewise, cultural or spiritual barriers and/or facilitators may have been missed, that more often impact racial minorities across Canada.This bias could potentially impact the generalizability of our results to racialized Canadian communities [e.g., Indigenous, Black, Indigenous, Persons of Colour, etc.].

Future directions
Several key barriers and facilitators to care for agitation and/or aggression among PLWD in LTC facilities were identified, at detection/diagnosis, care coordination/ management, and mild-to-moderate and acute/severe treatment.Given that these barriers were mapped to the TDF, future research efforts can form a substantial knowledge-to-action plan by mapping these TDF domains to the COM-B and subsequently the Behaviour Change Wheel.Therefore, appropriate implementation strategies can be created to change behaviours in LTC to eliminate these barriers to care.

Conclusions
This qualitative study used semi-structured interviews to identify the main barriers and facilitators to care for agitation and/or aggression among PLWD in LTC found that key barriers included a lack of validated tools to detect agitation and/or aggression, inconsistent and variable training practices among healthcare providers, and a limited number of non-pharmacological interventions available in LTC.Key facilitators were using an interdisciplinary team approach and having competent and trained healthcare providers to administer non-pharmacological interventions.Future research should look towards creating feasible implementation strategies to eliminate the identified barriers, in order to improve care outcomes among PLWD in LTC.

Fig. 1
Fig. 1 The most common facilitators and barriers to (a) the detection and diagnosis of agitation and/or aggression in LTC, (b) the care coordination and management of agitation and/or aggression in LTC, (c) the treatment of mild-to-moderate agitation and/or aggression in LTC, and (d) the treatment of acute/severe agitation and/or aggression in LTC

Table 1
The Demographic of Semi-Structured Interview Participants (n = 18)

Table 2
[24]s related to detection and diagnosis of agitation and/or aggression, mapped to the TDF and linked to the COM-B model[24]

Table 2
(continued) Drawbacks to tools to monitor agitation symptoms (e.g.not informative enough) Barrier Unclear awareness or availability of geriatric medicine or geriatric psychiatry services Barrier Diagnosis for agitation and/or aggression is made during the process of the dementia diagnosis Facilitator The high volume of assessments for other behavioural issues is part of the assessment for agitation Facilitator Documenting and recording agitation events in many places Facilitator Reviewing experiences of all care team members working with the resident to create a diagnosis of agitation and/or aggression Facilitator Emotion Diagnostic practices overlook hypoactive behaviours Barrier Residents are unique and agitation is especially unpredictable and fluctuates over time Barrier Residents' lack of awareness or expression Barrier

Table 3
Codes Related to Care Coordination and Management, Mapped to the TDF and the COM-B Model BarrierChanging language around agitated and aggressive behaviours to be more patientcentred Facilitator Healthcare providers need to be able to selfregulate when providing care to aggressive residents Facilitator Adequate training is provided to increase competency and expertise among LTC staff Facilitator Education of friend and family caregivers enables better agitation and/or aggression care among people with dementia in LTC Facilitator Education among healthcare providers for management approaches for agitation and/ or aggression enables better care Facilitator Staff from different cultural backgrounds respond differently to agitation Barrier Different healthcare providers perceive planning of care to be specific to their professional roles Barrier Ensuring that the follow-up of agitated symptoms is integrated into care practices Lack of training for healthcare providers caring for agitation or aggression among people with dementia Barrier Inconsistent training for health care providers caring for people with dementia with agitation Barrier

Table 3
(continued) Checklist of precipitants to consider (e.g.basic needs: food, drink, pain, medication, etc.) Facilitator Different healthcare providers perceive planning of care to be specific to their professional roles Barrier Staff from different cultural backgrounds respond differently to agitation Barrier Memory, Attention and Decision Making Processes Decline in mental status or increased dementia impeding care for agitation Barrier Resident personal qualities as barrier to care Barrier

Table 3
(continued) Facilitator "The hyperactive[resident]usually attracts the attention of everybody because they're distressed, yelling, screaming, fidgeting, wandering, moving, so they're active, whereas the hypoactive -that's where people can be missed" (Participant 3).

Table 4
Codes Related to Acute/Severe and Mild/Moderate Agitation and/or Aggression Treatment, mapped to the TDF and the COM-B Model.Codes related to acute/severe agitation and/or aggression are written in red, whilst those related to mild/moderate treatment are written in black

Table 4
(continued)An overall barrier for acute/severe agitation treatment was the reliance on physical and/or chemical restraints.As well, agitation symptoms being too severe served as a barrier to using non-pharmacological interventions for acute/severe agitation and/or aggression: